<div class="layuimini-container">
    <form id="app-form" class="layui-form layuimini-form">

        <div class="layui-form-item">
            <label class="layui-form-label">提现人</label>
            <div class="layui-input-block">
                <input type="text" name="realname" class="layui-input" disabled placeholder="请输入商家名称" value="{$row.realname}">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">银行卡号</label>
            <div class="layui-input-block">
                <input type="text" name="bankno" class="layui-input" disabled placeholder="请输入联系人" value="{$row.bankno}">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">银行名称</label>
            <div class="layui-input-block">
                <input type="text" name="bankname" disabled class="layui-input" placeholder="请输入银行名称" value="{$row.bankname}">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">转账单号</label>
            <div class="layui-input-block">
                <input type="text" name="paysn" lay-verify="required" class="layui-input" placeholder="请输入转账单号" value="{$row.paysn}">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">转账时间</label>
            <div class="layui-input-block">
                <input type="text" name="paytime" lay-verify="required" data-date="" data-date-type="datetime" class="layui-input" placeholder="请选择转账时间" value="{$row.paytime}">
            </div>
        </div>
        <div class="hr-line"></div>
        <div class="layui-form-item text-center">
            <button type="submit" class="layui-btn layui-btn-normal layui-btn-sm" lay-submit>确认转账</button>
            <button type="reset" class="layui-btn layui-btn-primary layui-btn-sm">重置</button>
        </div>
    </form>
</div>